Mother describes baby's final hours

A devastated mother wept as she described the moment her premature baby died hours after being removed from a ventilator.

Rohan Rhodes was born 15 weeks early at Singleton Hospital in Swansea, Wales, on August 27, 2012.

He was resuscitated after birth and put on a ventilator on the hospital's neonatal ward, where doctors believed he was "doing well".

Rohan was then moved to St Michael's Hospital in Bristol - in the same trust as Bristol Children's Hospital - to be assessed for an operation to close a heart duct which was open.

But just 24 hours after arriving, the decision was made to remove Rohan from the ventilator and his condition deteriorated rapidly.

He was 36 days old when he died.

Mother Bronwyn told an inquest a doctor later apologised to her and husband Alex after their son was removed from the machine and given breathing mask treatment Continuous Positive Airway Pressure (CPAP) instead.

Practising vet Mrs Rhodes said: "During the time Vel (Dr Velmurugan Ramalingam) was working on Rohan he apologised repeatedly.

"He said: 'Don't worry, we will take care of him'.

"I was repeatedly crying and shaking my head: 'But you haven't. You haven't taken care of my baby. He came here in good health for a procedure'.

"Vel kept saying he was so sorry."

She added: "There were other babies being ignored while..." before being stopped from continuing by the coroner.

Flax Bourton Coroner's Court heard Mrs Rhodes, of Narbeth, Pembrokeshire, was admitted to Withybush Hospital in west Wales on August 26, 2012.

She was just 25 weeks pregnant when Rohan was born in Singleton Hospital's Special Care Baby Unit the following day.

Dr Geraint Morris, a consultant paediatrician on the unit, described Rohan as being "extremely premature" and requiring ventilation.

Mrs Rhodes said: "The medical team tried to wean him off the ventilator from day one.

"He was a very healthy baby considering. He digested his food and consistently put on weight and grew. He was a very active baby."

The consultants believed it was impossible to wean Rohan off the ventilator any further, Mrs Rhodes said.

A medical team from Singleton transferred Rohan to St Michael's Hospital, where he was to be assessed for surgery on his open heart duct.

He arrived at the unit at 1.55pm on September 28. Mrs Rhodes said she quickly became concerned about the standard of care her baby received.

"That meant if the blood gas were suitable you would reduce the level of ventilation," she said.

"At no point did anybody say that this child was to remain ventilated, nor conversely that this child was to be extubated.

"Neither decision was conveyed to me.

"At approximately 1pm, I took a decision to reduce the rate the ventilator was breathing for him.

"Then, at 1.47, I took a capillary gas to check that hadn't had an effect on him.

"It wasn't until 4pm that I extubated Rohan to a bubble CPAP.

"It was my intention to do a blood gas one hour from extubating him but I was delayed because I was called to perform other duties.

"At around 6pm I was having a cup of coffee, I was called back to the room that Rohan was in."

She said Rohan had become bradycardic when his parents were caring for him and she reintubated him.

During questioning by the coroner, the nurses defended her decision to remove Rohan from the ventilator.

"The only plan was to wean Rohan off the ventilator as tolerated, the logical conclusion of such a plan was extubation," she said.

"Nurse practitioners, working as I work, we work autonomously.

"That was well within my remit. It was not an unreasonable thing to do."

The nurse said she was not aware of a plan for Rohan to have surgery on his heart duct in the following days, despite notes by colleagues stating this before the extubation.

"Had I known that the intention was surgery, I wouldn't have extubated," she said.

Speaking after the inquest, which will resume tomorrow, Rohan's parents said they hoped lessons would be learned from their son's death.

Mrs Rhodes said: "We felt that they did admit to some failings. There were some things that we didn't know.

"We are hoping for serious changes and we are hopeful that they are changing things so that other babies will never suffer the way Rohan suffered because he suffered a great deal of pain before he died.

"That's the part that we want to try and make sure doesn't happen again."

Mr Rhodes added: "They have a lot to learn from this I think - I hope."

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